Provider Demographics
NPI:1740862416
Name:COMSTOCK, MARK ALLEN X (LPN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:COMSTOCK
Suffix:X
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 W SUNNY SANDS RD
Mailing Address - Street 2:
Mailing Address - City:CATHLAMET
Mailing Address - State:WA
Mailing Address - Zip Code:98612-9724
Mailing Address - Country:US
Mailing Address - Phone:208-880-0103
Mailing Address - Fax:
Practice Address - Street 1:81 W SUNNY SANDS RD
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612-9724
Practice Address - Country:US
Practice Address - Phone:208-880-0103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60138496164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse